Alcohol Overuse and Abuse

Alcohol Overuse and Abuse ACLI Medical Section CME Meeting February 23, 2015 Daniel Z. Lieberman, MD Professor and Vice Chair Department of Psychiatry George Washington University

Alcohol OVERVIEW Definitions and Epidemiology Making the Diagnosis Treatment Effectiveness Alcohol Abuse in the Elderly Morbidity and Mortality

Definitions STANDARD DRINK

Definitions HEAVY DRINKING

Definitions BINGE DRINKING

Mechanism DOPAMINE

Mechanism DOPAMINE Dopamine neurons that project to the nucleus accumbens are inhibited by GABAergic neurons. GABA release from these neurons is in turn inhibited by the mu-opioid receptor (MOR). Alcohol stimulates the release of endogenous opioids such as β-endorphins (β-eps)

Mechanism DOPAMINE % of a drug s user s who are dependent US 1999 Nicotine Heroin Cocaine Sedatives Stimulants Marijuana Hallucinogens Pain relievers Alcohol Tranquilizers Inhalants Sources: EMCDDA, 2000 Annual Report; US Food & Drug Administration; SAMHSA National Household Survey on Drug Abuse

Distribution DRINKS PER WEEK

SAMHSA Mental Health Surveillance Study 2008-2012 The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. Repeated relapses Intense drug craving Medical morbidity Social impairment Risky use Men Women Alcohol Abuse 4.6% 1.7% Alcohol Dependence 4.6% 2.1% Abuse or Dependence 9.2% 3.8%

SAMHSA Mental Health Surveillance Study 2008-2012 18-25 26-49 50+ Alcohol Abuse 6.9% 3.6% 1.2% Alcohol Dependence 5.1% 4.2% 1.7% Abuse or Dependence 12.0% 7.8% 2.9%

Diagnosis SINGLE QUESTION SCREEN Do you drink alcohol? In the past year have you had more than 4 drinks (3 for women) on a single occasion? Have you noticed any problems associated with your drinking?

Diagnosis AUDIT Alcohol Use Disorders Identification Test Gold standard for evaluating alcohol use Ten item questionnaire takes 2 minutes to complete Three questions on amount and frequency Three questions on loss of control Four questions on problems caused by alcohol A score of 8 or greater indicates harmful drinking Compared to a lengthy diagnostic interview the AUDIT has a sensitivity of 0.86 and a specificity of 0.89

Diagnosis CAGE Easy to remember mnemonic Cut Down attempts Annoyed by people commenting on your drinking Guilty about drinking Eye opener to get going in the morning Not clinically useful Only identifies advanced alcoholism Not valid for women or minorities

Diagnosis LABORATORY TESTS Diagnostic Values of Markers of Alcohol Abuse and Dependence Alcohol Clin Exp Res, Vol 24, No 9, 2000; p 1414 1419

Treatment PSYCHOTHERAPY Project MATCH The Largest Trial Of Psychotherapies For Alcohol Problems Addiction (1999) 94(1), 31-69 Eight year multi-site study of three therapies involving 1,726 patients. No significant differences among therapies. Drinking days per month decreased from 25 to 6. Drinks per drinking day decreased from 15 to 3. Improvement was maintained at 12 months.

Medication DISULFIRAM Alcohol Disulfiram Reaction Headaches Nausea Chest pain Sweating Breathing difficulty Heart palpitations Anxiety Copious vomiting

Medication DISULFIRAM

Medication DISULFIRAM When the stakes are high enough, making the right choice is easy.

Medication NALTREXONE

Medication NALTREXONE (REVIA)

Medication ACAMPROSATE (CAMPRAL) Acamprosate has an unclear mechanism of action that may involve reduction of glutamate activity. Dose is 666 mg tid.

Medication ACTUAL USE

Substance Abuse in the Elderly NEW RISKS Some Stop and Some Start A 2001 government study found that 17% of people over the age of 60 abuse substances Some problem drinkers die early and some moderate their use, however at the same time, aging brings new risks for initiating substance abuse. Late onset alcohol problems accounted for 41% of patients over 65 enrolled in a Mayo Clinic alcohol treatment program.

Substance Abuse in the Elderly NEW RISKS Causes of Late Onset Alcohol Problems Higher blood alcohol concentration without increased consumption Less body fluid Loss of lean muscle mass Less active liver Compromised blood-brain barrier Situational factors can encourage drinking Retirement, loneliness, failing health, death of loved ones

Substance Abuse in the Elderly DIAGNOSIS Barriers to Recognition Typical warning signs may be absent due to lifestyle changes that occur with age. Warning Sign Marital difficulties Problems at work DWI Confounding Factor Widowed Retired Does not drive

Morbidity and Mortality THE GOOD AND THE BAD

Medication MORTALITY

Morbidity and Mortality TRAFFIC FATALITIES NIAAA Alcohol Facts and Statistics, July 2014

Morbidity and Mortality ALCOHOL POISONING There are 2,200 alcohol poisoning deaths in the US each year. Most alcohol poisoning deaths are among non- Hispanic whites. Alcohol dependence (alcoholism) was identified as a factor in 30% of alcohol poisoning deaths.

Morbidity and Mortality FATALITIES Often when we talk about alcohol-related problems, people assume it's about alcoholism and they're the ones causing all the problems, when in fact any of us can drink alcohol in excess. Because people occasionally binge drink and there are many more of them (than alcoholics), those non-addicted binge drinkers account for more problems in our society. Traci L. Toomey, PhD, Professor of Epidemiology, University of Minnesota Centers for Disease Control and Prevention, June 26, 2014

Morbidity and Mortality THE GOOD AND THE BAD

Morbidity and Mortality HEALTH BENEFITS Rates (SE) of death from all causes, all cardiovascular diseases, and alcohol-augmented conditions from 1982 to 1991, according to base-line alcohol consumption. Alcohol-augmented conditions are cirrhosis and alcoholism, alcohol-related cancers, breast cancer in women, and injuries and other external causes. N Engl J Med 1997;337:1705-14

Alcohol CONCLUSION About 10% of Americans live with alcohol abuse or dependence. Alcohol causes addiction by stimulating the brain s reward system. Treatment can be highly effective, but only a small sliver of those who would benefit from treatment receive it. Alcohol can cause or exacerbate illnesses in many organ systems, however at the same time it confers protection from other illnesses.